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Revista Brasileira de Psiquiatria. 2014;36:S21–S27 ß 2014 Associac¸a˜ o Brasileira de Psiquiatria doi:10.1590/1516-4446-2013-1218

UPDATE ARTICLE : considerations for ICD-11 Odile A. van den Heuvel,1,2 David Veale,3,4 Dan J. Stein5

1Department of , VU University Medical Center (VUmc), Amsterdam, The Netherlands. 2Department of Anatomy & Neurosciences, VUmc, Amsterdam, The Netherlands. 3Institute of Psychiatry, King’s College London, London, UK. 4Center for Disorders and Trauma, South London and Maudsley NHS Foundation Trust, London, UK. 5Department of Psychiatry, University of Cape Town, Cape Town, South Africa.

The World Health Organization (WHO) is currently revisiting the ICD. In the 10th version of the ICD, approved in 1990, hypochondriacal symptoms are described in the context of both the primary condition hypochondriacal disorder and as secondary symptoms within a range of other mental disorders. Expansion of the research base since 1990 makes a critical evaluation and revision of both the definition and classification of hypochondriacal disorder timely. This article addresses the considerations reviewed by members of the WHO ICD-11 Working Group on the Classification of Obsessive-Compulsive and Related Disorders in their proposal for the description and classification of hypochondriasis. The proposed revision emphasizes the phenomenological overlap with both anxiety disorders (e.g., , hypervigilance to bodily symptoms, and avoidance) and obsessive-compulsive and related disorders (e.g., preoccupation and repetitive behaviors) and the distinction from the somatoform disorders (presence of somatic symptom is not a critical characteristic). This revision aims to improve clinical utility by enabling better recognition and treatment of patients with hypochondriasis within the broad range of global health care settings. Keywords: Hypochondriasis; illness ; obsessive-compulsive and related disorders; definition; classification

Introduction caused by medical conditions and that warrant medical evaluation and/or treatment. Certainly, from an evolu- The World Health Organization (WHO) is currently tionary perspective, an appropriate level of anxiety and revising the ICD. The 10th version of the ICD1 was response to somatic alarm symptoms may have adaptive approved in 1990, almost 25 years ago. The development value. However, when concern about health becomes a of ICD-11 requires attention to the relevant historical matter of preoccupation and continuous fear or distress, it background as well as to more recent developments interferes with daily life. in understanding of clinical entities related to illness Individuals with such concerns may meet the diagnos- preoccupation and fear. This article addresses the requirements of the DSM-IV-TR5 and ICD-101 diag- question of how hypochondriasis should be described noses of hypochondriasis and hypochondriacal disorder, and classified in the ICD-11, and addresses the con- respectively. Hypochondriasis has negative effects on siderations reviewed by the members of the WHO ICD-11 quality of life, social and occupational functioning, and Working Group on the Classification of Obsessive- health care resource utilization, and is thus an important Compulsive and Related Disorders in their proposal for to recognize and treat in clinical practice. the description and classification of this disorder. Although health care practitioners are familiar with those Preoccupation with bodily symptoms and fear of patients who seek reassurance during repeated visits to suffering from a serious falls on a continuum health care services, resulting in high health care costs, ranging from a very mild concern about some unusual unnecessary diagnostic interventions, and disturbed bodily sensation or observation to severe preoccupation patient-doctor relationships, hypochondriasis can also and fear or conviction in individuals in whom thoughts and lead to severe avoidance, risking unfavorable delays in actions are centered around the overestimated risk of case of actual . In most patients with hypochon- 2 having or developing a serious, life-threatening illness. driasis, symptoms wax and wane, with acute exacerba- Taxometric studies have empirically confirmed that tions triggered by stressful periods – e.g., due to loss of a anxiety about health is a dimensional rather than a family member, a past experience of actual organic 3,4 categorical construct. Normal expressions of concern disease, and social circumstances, or in response to about health and alertness towards bodily symptoms may hospital and disease-related items in the mass media.6 be a useful response to changes in the body that are

Correspondence: Odile A. van den Heuvel, Department of Historical background Psychiatry, VU University Medical Center, PO Box 7057, 1007 MB, Amsterdam, The Netherlands. Hypochondriasis as a psychiatric concept has been the E-mail: [email protected] subject of considerable controversy over the centuries. S22 van den Heuvel et al.

Today, hypochondriasis is considered a mental disorder, of self-directed exposure and cognitive change (cognitive but in the 17th century it referred to a common somatic reappraisal) are successful in the reduction of discomfort condition, with the name hypochondria, introduced by and attenuation of the urge to seek reassurance. Hippocrates and literally meaning ‘‘below the cartilage,’’ The long-lasting debate on both the terminology and suggesting the involvement of abdominal organs. The the conceptualization of hypochondriasis is currently transformation of the description over time, with the initial focused on the following issues12: 1) is hypochondriasis reference to a mental condition occurring in the early 19th a distinct primary medical entity or a secondary feature of century, has been described extensively by Noyes.7 other ? 2) what are the discriminating Briefly, 17th century authors, still strongly influenced by diagnostic features of hypochondriasis and how can Galen’s views of pathogenesis, related hypochondriasis these be differentiated from normality? and 3) how best to to melancholic personality traits, caused by somatic classify hypochondriasis, taking into account its relation digestive disturbances. Psychological concepts became to somatoform disorders, anxiety disorders, and obses- more prominent in the description of hypochondriasis sive-compulsive and related disorders (OCRD)? Here, we from the late 18th century onward. At that time, it was summarize the existing but limited literature on these thought that a depressive ‘‘morbid’’ state would change issues, as well as recent developments in relation to body awareness, resulting in digestive disturbances. DSM-5, and propose the options for ICD-11. Although attention started to switch from the intestines to the brain in the 19th century, hypochondriasis became The ICD-10 approach to hypochondriasis regarded as a , i.e., a functional rather than structural disturbance. Fear of serious illness was In the ICD-10 Clinical Descriptions and Diagnostic emphasized as its principal characteristic, digestive Guidelines for mental and behavioral disorders,13 hypo- symptoms were no longer considered as crucial, and chondriacal symptoms are described in the context bodily preoccupation and hypervigilance and abnormal of both the primary condition hypochondriasis and illness behaviors started to receive attention. During as secondary symptoms of a range of other mental this ‘‘physical-to-mental’’ transformation of the concept entities (e.g., and ). of hypochondriasis, it became one of many mental Hypochondriacal disorder (F45.2) is included in the disorders. The historical review by Noyes, mainly focus- grouping of somatoform disorders. Its main character- ing on the 17th, 18th, and 19th centuries, shows the istics are: 1) the persistent in the presence of at influential role of social and cultural factors in shaping the least one serious physical illness underlying the present- description of the disorder over time, and the uncertainty ing symptom(s), even though repeated investigations and about how to classify the disorder in relation to other examinations have identified no adequate physical clinical entities. explanation, or a persistent preoccupation with a pre- Psychodynamic theories of hypochondriasis mainly sumed deformity or disfigurement; and 2) the persistent focused on the role of (unconscious) guilt over sexual refusal to accept the advice and reassurance of several and hostile wishes, fantasies, and feelings that must be different doctors that there is no physical illness or disguised to avoid overwhelming fear of punishment, underlying the symptoms. Five partially 8 bodily damage (castration), and death. The psychody- overlapping inclusion terms are listed for hypochondriacal namic term hypochondriacal neurosis was adopted by disorder, i.e., , dysmorphopho- DSM-II, and despite criticism of and controversy about bia, hypochondriacal neurosis, hypochondriasis, and both the relevant terminology and construct, the terms , indicating that any of these phenomena hypochondriasis and hypochondriacal disorder persisted should be assigned the diagnosis of hypochondriacal 9 in subsequent revisions of DSM and ICD. disorder. Current concepts of hypochondriasis have been Based on more recent research,2 some aspects related considerably influenced by cognitive-behavioral to the definition of the clinical entity, its relationship to approaches.2 Salkovskis & Warwick, for example, have related conditions, and its classification within the suggested that preoccupation with (ill) health is the key somatoform category need to be reconsidered. First, cognitive component, while seeking of reassurance from the presence of a physical symptom is not crucial for the physicians and repeated checking of the body is the most diagnosis of hypochondriasis, since in many cases crucial behavioral component.2 These authors put for- preoccupation with or fear for a serious illness exists ward the idea that repetitive reassurance seeking is a without actual somatic symptoms.14 Second, patients form of avoidance which serves to maintain the pre- with hypochondriasis seek out reassurance and are occupation with health, just as compulsions increase the happy to learn that there is no immediate threat (in impact of obsessions and distress over the long term in contrast to most patients with other somatoform dis- patients with obsessive-compulsive disorder (OCD).10,11 orders, who seek a diagnosis and keep on seeking for Since medical reassurance results in immediate relief one), but fail to maintain the immediate feeling of relief followed by the longer-term return of anxiety, they after medical reassurance, due to the recurrent preoccu- proposed that these avoidance behaviors are important pation or concern and return of fear, resulting in maintaining factors and a major focus for treatment. Their avoidance, repetitive reassurance seeking, or other case reports indicate that treatments focused on elimina- repetitive behaviors.15 Although checking behaviors and tion of reassurance (response prevention) and facilitation reassurance seeking give some relief, the reduction in

Rev Bras Psiquiatr. 2014;36(Suppl 1) Hypochondriasis in ICD-11 S23 fear is transient.16 Some patients predominately experi- , psychological factors affecting other ence repetitive behaviors, whereas other patients mainly medical conditions, and factitious disorders. Depending show strong avoidance or switch between avoidance and on the symptoms of the individual, and particularly on the checking behaviors over time. A third issue that requires presence or absence of somatic symptoms, an individual reconsideration, based on WHO’s priority that ICD-11 be patient that would have been diagnosed with hypochon- globally applicable,17 is the requirement in the diagnostic driasis in DSM-IV will now be diagnosed as having illness guidelines for hypochondriacal disorder that the individual anxiety disorder (if the somatic symptoms are absent or have interacted with several different doctors who have mild) or as having (if one or not found an adequate medical cause for the experienced more somatic symptoms are present and are distressing symptoms. It is problematic in the context of a global or result in significant disruption of daily life). Within the system to define primary diagnostic entities based on illness anxiety disorder entity, two specifiers have been patterns of access to specific types of health care services. defined: 1) a care-seeking type with high health care utilization; and 2) a care-avoidant type. The DSM-IV approach to hypochondriasis The definition of illness anxiety disorder is specific and includes a cognitive component (preoccupation), an af- In the DSM-IV-TR,5 hypochondriasis and body dys- fective component (substantial anxiety), and a behavioral morphic disorders are separate entities within the group- component (care-avoidant and care-seeking health- ing of somatoform disorders. This is consistent with the related behaviors). The definition of somatic symptom growing literature indicating that body dysmorphic dis- disorder, on the other hand, is broader (‘‘thoughts, order is a distinct entity with diagnostic validity and clinical feelings and behaviors related to present somatic utility.18 The diagnostic criteria for hypochondriasis in symptoms’’). The definition of illness anxiety disorder DSM-IV include the preoccupation with or fear for a does not include the feature ‘‘hypervigilance to bodily serious disease, based on the person’s misinterpretation symptoms’’ as a diagnostic criterion, but mentions that of bodily symptoms.2 DSM-IV also includes a minimal ‘‘the individual is easily alarmed about personal health duration of 6 months and an optional specifier, ‘‘poor status.’’ Both entities include a duration criterion of at insight,’’ for patients who do not recognize that the least 6 months to underline the chronicity of the disorders. concern is excessive or unreasonable. No insight specifiers have been defined for illness anxiety In the context of diagnostic classification in DSM-IV-TR disorder and somatic symptom disorder, in contrast to and ICD-10, and now also DSM-5 (see below), hypo- some related disorders classified in other groupings, such chondriasis is considered a somatoform disorder,1,5,14 as OCD and body dysmorphic disorder. A potential but it has always been at the crossroads of different problem with this formulation is the lack of clarity inherent categories (Table 1). The fact that the presence of in the overlapping criteria of somatic symptom disorder somatic symptoms is not a diagnostic requirement for and illness anxiety disorder. A broader potential problem hypochondriasis is arguably inconsistent with its classi- is the retention of the entire concept of hypochondriasis in fication within the somatoform disorders. Moreover, given the grouping of somatic symptom and related disorders, that the key clinical features (preoccupation, anxiety, instead of incorporating it into the anxiety disorders bodily hypervigilance, and avoidance behaviors) and grouping or the OCRD grouping. This seems particularly the most effective treatment strategy (cognitive behavior questionable, since illness anxiety disorder does not therapy, mostly including exposure in vivo with response depend on the presence of somatic symptoms and clearly prevention) in hypochondriasis largely overlap with those shares clinical characteristics with disorders in other for anxiety disorders such as , social groupings. anxiety disorder, generalized anxiety disorder (GAD), and OCD, classification within the anxiety disorders category or the OCRD category would be more consis- Considerations for ICD-11 tent with the more recent conceptualizations of the Phenomenology disorder.2 The Working Group proposes the following phenotype Illness anxiety disorder and somatic symptom definition: hypochondriasis refers to a persistent pre- disorder in DSM-5 occupation with or fear about the possibility of having or developing one or more serious progressive or life- In DSM-5, the concept of hypochondriasis is partly threatening diseases. The preoccupation is associated reflected in illness anxiety disorder and partly in somatic with a hypervigilance to and catastrophic misinterpreta- symptom disorder, two separate disorders within the tion of bodily signs or symptoms, including normal or grouping of somatic symptom and related disorders commonplace sensations, and is accompanied by avoid- (formerly known as somatoform disorders).14 The com- ance and/or repetitive behaviors. The preoccupation and/ mon feature across different disorders within the somatic or fear is not simply a reasonable concern related to a symptom and related disorders grouping is the promi- specific context of the patient, it persists or reoccurs nence of somatic symptoms associated with signifi- despite appropriate medical evaluation and reassurance, cant distress and impairment. This grouping comprises and causes clinically significant distress or impairment in somatic symptom disorder, illness anxiety disorder, important areas of functioning.

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Table 1 Hypochondriasis in ICD-10, DSM-IV-TR, and DSM-5, and the proposal for ICD-11 ICD-101 DSM-IV-TR5 DSM-514 ICD-11 (proposal) Category Somatoform disorders Somatoform disorders Somatic symptom and related Primary: OCRD disorders Secondary: anxiety disorders Name Hypochondriacal disorder Hypochondriasis (300.7) Illness anxiety disorder Hypochondriasis (illness (F45.2)* (300.7) anxiety disorder) Diagnostic A) Persistent belief in the A) Preoccupation with A) Preoccupation with A) Persistent preoccupation criteria presence of at least one of having, or the idea that having or acquiring a with or fear about the serious physical illness one has, a serious disease serious illness possibility of having one or underlying the presenting based on the person’s B) Somatic symptoms are more serious progressive or symptom(s), even though misinterpretation of bodily not present or, if present life-threatening diseases repeated investigations and symptoms are only mild in intensity. B) The preoccupation is examinations have identified B) The preoccupation If another medical condition associated with a no adequate physical persists despite appropriate is present or there is a hypervigilance to and a explanation medical evaluation and high risk for developing a catastrophic or: reassurance medical condition, the misinterpretation of bodily Persistent preoccupation with C) The belief is not of preoccupation is clearly signs or symptoms, a presumed deformity or delusional intensity (as in excessive or including normal or disfigurement delusional disorder, somatic disproportionate commonplace sensations B) Persistent refusal to type) and is not restricted C) High level of anxiety C) The preoccupation or accept the advice and to a circumscribed concern about health, and the fear is not simply a reassurance of several about appearance (as in individual is easily alarmed reasonable concern to a different doctors that there body dysmorphic disorder) about personal health specific context of the is no physical illness or D) The preoccupation status patient and it persists or abnormality underlying causes clinically significant D) Excessive health-related reoccurs despite the symptoms distress or impairment in behaviors or maladaptive appropriate medical social, occupational, or avoidance evaluation and reassurance other important areas of E) Symptom duration at D) One or more of the functioning least 6 months following behaviors occur E) The duration of the F) Not better explained by in relation to the disturbance is at least 6 another mental disorder preoccupation or fear: months avoidance, checking, F) The preoccupation is not information seeking, and/or better accounted for by requests for reassurance generalized anxiety E) The preoccupation or disorder, obsessive- fear causes clinically compulsive disorder, panic significant distress or disorder, major depressive impairment in important disorder, separation anxiety, areas of functioning or another somatoform F) The diagnosis also disorder includes those with no insight or with delusional beliefs Specifiers Poor insight Care-seeking type No insight Care-avoidant type OCRD = obsessive-compulsive and related disorders. * Includes body dysmorphic disorder, dysmorphophobia (nondelusional), hypochondriacal neurosis, hypochondriasis, and nosophobia.

As the definition indicates, the phenotype is character- with panic disorder, but panic attacks are a core feature ized by four main domains of dysfunction: preoccupation of panic disorder.24 Individuals with panic disorder may and misinterpretation (cognitive component); fear/anxiety worry that the somatic symptoms they experience (affective component); hypervigilance to bodily symptoms during panic attacks are evidence of serious medical (attentional component); and avoidance and repetitive illness (e.g., ), and individuals behaviors (behavioral component). The preoccupations with hypochondriasis may experience panic attacks in show overlap with worries in patients with GAD,19,20 but in response to health-related stimuli (e.g., emergence of a GAD the concerns have a more general content, often new symptom or exposure to health information); thus, in related to daily activities, and there are a range of other cases of hypochondriasis where illness concerns are concerns as well. The preoccupations also show overlap mainly related to the cardiovascular system, differentia- with the obsessions of OCD,21,22 but the major difference tion of the two disorders may be difficult. Another is that, in hypochondriasis, the thoughts are only related important issue related to is that the concern of having or developing a serious illness. avoidance and repetitive safety-seeking behaviors (e.g., Rumination about illness has shown to be the key body checking, information seeking, reassurance seek- symptom in patients with hypochondriasis.23 ing) are common in patients with OCD25 and body Hypervigilance to and catastrophic misinterpretation of dysmorphic disorder26 as well. Although the phenotype bodily signs or symptoms is also present in patients of hypochondriasis shows little overlap with somatoform

Rev Bras Psiquiatr. 2014;36(Suppl 1) Hypochondriasis in ICD-11 S25 disorders, some patients with hypochondriasis may pre- largely overlaps with that of most anxiety disorders and of sent with somatic symptoms. In patients with hypochon- OCD: cognitive-behavioral therapy, including exposure in driasis, in contrast to those with somatoform disorders, the vivo and response prevention.31 distress is typically focused on the possibility that the In the process of moving hypochondriasis to a grouping symptoms indicate a serious undiagnosed illness, with more closely related diagnostic features, two good whereas distress among somatoform patients tends to alternatives exist. Most key characteristics of hypochon- be focused on the symptoms themselves. Both groups driasis, i.e., anxiety, hypervigilance to and catastrophic may seek medical attention for their symptoms, but misinterpretation of bodily symptoms, and avoidance, patients with hypochondriasis are typically reassured by strongly resemble the phenotype of anxiety disorders, appropriate clinical examination and investigations and particularly panic disorder.29 In two comparative brain reassurance by health care providers, though the effects of imaging studies on attentional bias27 and executive such reassurance may be temporary. functioning28 in OCD, panic disorder, and hypochondria- Some comparative studies have been published on the sis, the task-related neural activation patterns showed phenomenological and neurobiological overlap and differ- both overlap and differentiation between the disorders. entiation between hypochondriasis, panic disorder, and Gropalis et al. compared 65 patients with hypochondria- OCD.27-29 These studies show that hypochondriasis sis, 94 patients with somatoform disorders (including shares characteristics with both disorders (panic attacks, disorder, undifferentiated somatoform dis- obsessions, compulsions, attentional bias to disorder- order, and somatoform disorder), and 224 patients specific or threat-related information, and aberrant with anxiety disorders (including panic disorder with/ recruitment of frontostriatal and limbic brain circuits), yet without , GAD, and OCD) with regard to also suggest that hypochondriasis is a separate entity. demographic variables, clinical features and naturalistic In most patients with hypochondriasis, symptoms wax treatment outcomes.32 They found a closer connection and wane over time. Both the behaviors and associated between hypochondriasis and anxiety disorders than insight can change significantly during the course of the between hypochondriasis and somatoform disorders.32 disorder. Furthermore, in cases with poor insight, it is Given the repetitive characteristics of hypochondriasis, important to diagnose hypochondriasis and to differenti- both cognitive (i.e., preoccupation) and behavioral (i.e., ate it from delusional disorder and other psychotic compulsive checking of the body and internet, repetitive disorders, as this distinction has important clinical seeking for reassurance from health professionals), and implications. Although most of the relevant literature is its overlap with OCD22,33 and body dysmorphic disorder,18 based on patients with delusional and nondelusional body which will be classified in ICD-11 as OCRD, classification dysmorphic disorder, hypochondriasis and body dys- of hypochondriasis with these disorders would be a viable morphic disorder are more similar than different in this alternative option. Considering the fact that body dys- regard, including in their response to pharmacological morphic disorder and hypochondriasis were both included treatment.30 Thus, one might expect the same issues to as part of the ICD-10 diagnosis of hypochondriacal arise in hypochondriasis. disorder, the most conservative approach would be to keep both disorders in the same grouping; the OCRD, Classification which, in turn, are closely related to the anxiety disorders. Since hypochondriasis shares symptoms with OCD33 and Hypochondriasis is a separate diagnostic entity that lies responds to the same treatments (cognitive-behavioral 34,35 exactly at the crossroads of three categories, showing therapy and ), classifica- overlap with somatoform disorders (now called somatic tion within the OCRD category could add to the clinical symptom and related disorders in DSM-5), anxiety utility of the classification system. Although the same disorders, and OCRD. arguments hold for the overlap with other anxiety The least optimal classification is among the somato- disorders, justifying an additional cross-linkage of hypo- form disorders. Although this classification might be chondriasis with the anxiety disorders, this is not the case intuitively appealing for those patients who present with for the somatoform disorders. many somatic symptoms, there are three reasons to question this approach. First, in many patients with Terminology hypochondriasis, somatic symptoms are absent or mild, and, if they are present, the interference with daily Not only has the conceptualization of hypochondriasis functioning does not result from the somatic symptoms been a matter of debate for centuries, but the name themselves, but is rather the consequence of fear about hypochondriasis itself has been controversial for decades, the symptoms and the related behavior. Second, patients due to its potentially confusing and pejorative aspects. with hypochondriasis are eager to find reassurance that Depending on the conceptualization of the disorders, nothing serious is happening in their body (although such alternative terms have been proposed during the last 3 reassurance only results in transient relief of distress and decades: abnormal illness behavior,36 disease ,37 may maintain preoccupation over the long term), patients illness phobia,38 health anxiety,2,39 for with other somatoform disorders wish for a diagnosis. illness,40 illness preoccupation disorder,13 heightened Third, the therapeutic approach to hypochondriasis differs illness concern (Fallon scale), and, now, in DSM-5, illness from the treatment of most somatoform disorders, but anxiety disorder and somatic symptom disorder. Con-

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sidering the main characteristics of the disorder, ill- sources: The International Union of Psychological ness anxiety disorder or illness preoccupation disorder Science, the National Institute of (USA), would be reasonable alternatives for the term hypochon- the World Psychiatric Association, the Spanish Foun- driasis. Although the term hypochondriasis has some dation of Psychiatry and Mental Health (Spain), and archaic and pejorative elements, the phrase illness anxiety the Santander Bank UAM/UNAM endowed Chair for may not be easily translated across all languages, and it is Psychiatry (Spain/Mexico). DV has received salary not logically or clinically useful to categorize and entity support from the National Institute for Health Research titled anxiety disorder in a grouping other than the anxiety (NIHR) Biomedical Research Centre for Mental Health disorders. A compromise would be to keep the name at South London and Maudsley NHS Foundation Trust hypochondriasis while including the term illness anxiety and the Institute of Psychiatry, King’s College London. disorder as a synonym. This synonym is consistent with a DJS is supported by the Medical Research Council of second parent classification of hypochondriasis among the South Africa. anxiety disorders and would also maintain continuity with DSM-5. Disclosure

OAH, DV, and DJS are members of the WHO ICD-11 Conclusion Working Group on the Classification of Obsessive- For ICD-11, the Working Group proposes that hypochon- Compulsive and Related Disorders, reporting to the driasis be included within the grouping of OCRD, with International Advisory Group for the Revision of ICD-10 illness anxiety disorder listed as a synonym, and that it Mental and Behavioural Disorders. Unless specifically be cross-referenced to the anxiety disorders grouping. stated, the views expressed in this article are those of the Hypochondriasis is defined as a persistent preoccupation authors and do not represent the official policies or with or fear about the possibility of having or developing positions of the Working Group, of the International one or more serious progressive or life-threatening Advisory Group, or of the WHO. diseases, accompanied by hypervigilance to and cata- OAH has received speaker’s honoraria from Eli Lilly strophic misinterpretation of bodily signs or symptoms, and Lundbeck. DJS has received research grants and/or including normal or commonplace sensations, resulting consultancy honoraria from AMBRF, Biocodex, Cipla, in both avoidance and reassurance-seeking behaviors, Lundbeck, the National Responsible Gambling Foundation, Novartis, Servier, and Sun. The other author reports no persisting or reoccurring despite medical evaluation and conflicts of interest. reassurance. The definition shows considerable overlap with anxiety disorders and OCRD. Classification among the OCRD, with cross-linkage to the anxiety disorders, References could improve the recognition of the disorder and encourage the use of appropriate treatments within the 1 World Health Organization (WHO). International classification of broad range of global health care settings. We also diseases and related health problems, 10th revision. Geneva: WHO; propose that an insight specifier be applicable for 1992. 2 Salkovskis PM, Warwick HM. Morbid preoccupations, health anxiety hypochondriasis, as with OCD and body dysmorphic and reassurance: a cognitive-behavioral approach to hypochondria- disorder, based on the common clinical features of these sis. Behav Res Ther. 1986;24:597-602. disorders and the relevance of the level of insight for 3 Ferguson E. A taxometric analysis of health anxiety. Psychol Med. treatment planning. 2009;39:277-85. 4 Longley SL, Broman-Fulks JJ, Calamari JE, Noyes R, Wade M, Orlando CM. A taxometric study of hypochondriasis symptoms. Behav Ther. 2010;41:505-14. Acknowledgements 5 American Psychiatric Association. Diagnostic and Statistical Manual The authors wish to thank the other members of the of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Arlington: American Psychiatric Publishing; 2000. WHO ICD-11 Working Group on the Classification of 6 Taylor S, Admundson GJ. Treating health anxiety: a cognitive- Obsessive-Compulsive and Related Disorders for their behavioral approach. New York: Guilford; 2004. comments on a previous draft of this manuscript: M 7 Noyes R Jr. The transformation of hypochondriasis in British Atmaca, NA Fineberg, LF Fontenelle, JE Grant, J Reddy, medicine, 1680-1830. Soc Hist Med. 2011;24:281-98. 8 Lipsitt DR. Psychodynamic perspectives on hypochondriasis. In: HB Simpson, P Hove Thomsen, and DW Woods. We are Stacevic V, Lipsitt DR, editors. Hypochondriasis: modern perspectives also grateful to GM Reed (senior project officer, Revision on an ancient malady. Oxford: Oxford University; 2001. p. 183-99. of the ICD-10 Mental and Behavioral Disorders, De- 9 Hyler SE, Sussman N. Somatoform disorders: before and after DSM- partment of Mental Health and , WHO), II. Hosp Community Psychiatry. 1984;35:469-78. and MB First (consultant to the WHO Department of 10 Rachman SJ. Some similarities and differences between obses- sional ruminations and morbid preoccupations. Can Psychiatr Assoc Mental Health an Substance Abuse and to the J. 1974;18:71-4. International Advisory Group for the Revision of the 11 Rachman S. The passing of the two-stage theory of fear and ICD-10 Mental and Behavioural Disorders) for their useful avoidance: fresh possibilities. Behav Res Ther. 1976;14:125-31. contribution to the discussion. 12 Stein DJ. Hypochondriasis in ICD-11. World Psychiatry. 2012;11: 100-4. The Department of Mental Health and Substance 13 World Health Organization. The ICD-10 classification of mental and Abuse, WHO, has received direct support that contrib- behavioural disorders: clinical description and diagnostic guidelines. uted to the activities of the Working Group from several Geneva: WHO; 1992.

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